Anticoagulation after ICH linked to better odds of functional recovery

Patients who resume oral anticoagulation treatment (OAT) following intracerebral hemorrhage (ICH) are almost twice as likely to achieve functional recovery, according to a study published Oct. 9 in Stroke.

Researchers led by Meredith P. Murphy, of Massachusetts General Hospital, said the question of whether to prescribe OAT following ICH remains an ongoing clinical dilemma. Roughly 80 percent of ICHs occur during treatment of atrial fibrillation (AFib) with anticoagulants, which are designed to limit cardioembolic stroke but raise the risk of bleeding events including ICH. Striking an ideal balance between those competing risks is a goal of clinicians caring for patients with AFib.

To shed further light on the relationship between OAT, cardioembolic stroke risk and functional recovery after ICH, Murphy et al. pooled patient-level data from three studies of ICH. The observational studies featured 941 ICH survivors, 262 of whom resumed OAT.

Patient who received that treatment following ICH were 89 percent more likely to experience functional recovery, defined as a modified Rankin scale score of 3 or less at one year after being discharged with scores higher than 3.

Each one-point increase in CHAD2S2-VASc score—which quantifies cardioembolic stroke risk—was associated with 17 percent decreased odds of functional recovery. However, patients with higher CHAD2S2-VASc scores were 1.74 times more likely to receive OAT and showed the most relative benefit for the therapy; patients with discharge scores of 3 to 4 showed a 1.33-fold increase in functional recovery versus a 2.55-fold increase in functional recovery for those with CHAD2S2-VASc scores from 7 to 9.

“We identified an interaction between cardioembolic stroke risk and OAT resumption, suggesting that embolic risk (influenced by OAT resumption) is likely to be central to the association between CHAD2S2-VASc scores and functional outcome,” the authors wrote.

Although they excluded patients with recurrent ICH or ischemic stroke from their analysis, Murphy and colleagues noted OAT may have reduced smaller, asymptomatic infarcts that nevertheless limit cognitive recovery.

“Previous studies clarified that ICH survivors are at high risk for dementia; atrial fibrillation may further increase risk for cognitive impairment, in itself a major obstacle to rehabilitation and recovery after stroke. Several additional biological observations can also be invoked to account for our findings, including decreased cerebral perfusion (as a result of reduced cardiac output) and proinflammatory state because of atrial fibrillation,” they wrote.

The authors noted individuals deemed at higher risk of ischemic stroke may have additional resources devoted to their care given their larger burden of comorbidities, which may have influenced the analysis. They said their findings support including recovery metrics, including motor and cognitive skills, in future randomized trials of anticoagulant resumption after ICH.